Barton Palmer is a Staff Psychologist; Samantha Friend, Steve Huege, and James Lohr are Psychiatrists; Mallory Mulvaney is a Research Associate; all at the Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System in California. Barton Palmer is a Professor-in- Residence, Steve Huege is a Clinical Professor, and James B. Lohr is Professor Emeritus; all at the Department of Psychiatry, University of California, San Diego in La Jolla. James Lohr is Professor Emeritus at the Department of Neurosciences, University of California, San Diego in La Jolla. Albaraa Badawood and Abdulaziz Almaghraby are Visiting Scholars; both at the Health Sciences International, University of California, San Diego in La Jolla. Correspondence: Barton Palmer (bpalmer@ucsd.edu)
Author disclosures The authors report no actual or potential conflicts of interest regarding this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
There is very little empirical evidence guiding pharmacologic approaches to PTSD in older veterans. This population is at increased risk for many comorbidities, and pharmacologic treatments many require dosage adjustments, as is the case for any geriatric patient. Selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) medications have been proposed for some cases of PTSD.59,60 Health care providers may consider the SSRIs escitalopram or sertraline preferentially given their decreased potential for drug-drug interactions, anticholinergic effects, or cardiac toxicity compared with that of other drugs in this class.60,61 As venlafaxine can increase blood pressure, especially at higher doses, prescribers may choose duloxetine as an alternative if a SNRI is indicated.60 For veterans when prazosin is being considered for nightmare control, monitoring for hypotension, orthostasis, and the administration of other antihypertensives or prostatic hypertrophy medications is necessary.61 The use of benzodiazepines, while not recommended for PTSD, should be viewed with even greater trepidation in a geriatric population given enhanced risk of falls and confusion in the geriatric veteran population.60,62
Conclusions
Many of the oldest veterans (aged > 80 years) are from the Korean War era. The harsh and unique nature of the war, as well as the differences in context and support from the US public, and the outcome of the war, may have all contributed to and elevation of “combat fatigue” and PTSD among combat veterans from the Korean War. As the “forgotten war” cohort also has been forgotten by researchers, relatively little is known about posttraumatic stress sequelae of these veterans in the decades following the war.
From available evidence, we can readily surmise that problems were underrecognized and suboptimally diagnosed and treated. There is tentative evidence supporting the use of standard interviews and rating scales, such as the CAPS, M-PTSD, and PCL, but lower cut-scores than applied with Vietnam and later veteran cohorts are generally recommended to avoid excessive false negative errors. In terms of psychotherapy treatment, there is again a stark paucity of systematic research, but the limited evidence from studies of PTSD treatment in older adults from the general population tentatively support the acceptability and potential efficacy of recognized evidence-based trauma-focused psychotherapies for PTSD. Research on medication treatment is similarly lacking, but the general recommendations for the use of SSRI or SNRI medications seem to be valid, at least in our clinical experience, and the general rules for geriatric psychopharmacology definitely apply here—start low, go slow.
There are several important avenues for future research. Most pressing among these are establishing the effectiveness of existing treatments, and the modifications that may be needed in the broader context of the above factors, as well as the physical and cognitive changes associated with advanced age. Further research on the phenomenologic aspects of PTSD among Korean War and subsequent cohorts are also needed, as the information obtained will not only guide more effective personalized treatment of the Korean War veterans who remain with us, but also inform future generations of care in terms of the degree and dimensions of variability that may present between cohorts and within cohorts over the life span.
